Retrospective review of eighteen patients with sacral fracture dislocations and cauda equina deficits treated with posterior sacral decompression and lumbopelvic fixation. At mean nineteen-month follow-up, all fractures healed without loss of alignment despite immediate full weight-bearing. Fifteen patients (83%) improved neurologically, and ten patients (56%) had full bowel/ bladder recovery. Complications consisted mainly of infection (17%) and asymptomatic rod breakage (33%). This series demonstrates the clinical effectiveness of lumbopelvic fixation, allowing the application to sacral injuries of decompression and fixation principles commonly used in fractures with neurologic deficits that occur in more rostral areas of the spine.

To evaluate the results of sacral decompression and lumbopelvic fixation for sacral fracture-dislocations with neurologic deficits.

Lumbopelvic fixation provided the stability necessary for full weight-bearing without loss of fracture reduction despite extensive sacral decompression. The functional neurologic improvement in most patients and complete neurologic recovery in all but one patient with intact lumbosacral roots are encouraging. The effectiveness of lumbopelvic fixation facilitates the application of principles of early decompression and stabilization to sacral fracture-dislocations.

Sacral fractures healed in all eighteen patients without loss of reduction. Average sacral kyphosis improved from forty-one to twenty-four degrees. Fifteen patients (83%) had normalization or improvement of bowel and bladder deficits, although only ten patients (56%) had improved Gibbons scores. Average Gibbons type improved from four to 2.8 at nineteen-month average follow-up. Rod breakage (33%) and infection (17%) were the most common complications. Recovery of bowel and bladder function was less likely in patients with disruption of any lumbosacral root (36% vs. 86%, p=.066) and complete deficits (47% vs. 100%, p=.241) although the small cohort size precluded statistical significance.

Retrospective review of medical records, radiographs, and prospectively collected data of eighteen consecutive patients with sacral fracture-dislocations and cauda equina deficits identified between 1997 and 2002 through institutional databases. Treatment consisted of open reduction, sacral decompression and lumbopelvic fixation. Radiographic and clinical results of treatment were evaluated. Neurologic outcome was measured by Gibbons’ criteria.

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Retrospective review of seventeen consecutive survivors of craniocervical dissociation (CCD). Thirteen patients had delay in diagnosis, with associated neurologic deterioration in five. Diagnosis of CCD was entertained after lateral C-spine x-ray in only two patients, and after screening C-spine CT in two others. At fifteen-month average follow-up, mean ASIA motor score improved from fifty preoperatively to seventy-nine postoperatively. One patient had temporary postoperative neurologic decline. There were no pseudarthroses. The diagnosis of CCD is often missed, with potentially severe neurologic consequences. Early diagnosis and stabilization are neuroprotective. A classification that identifies minimally displaced yet unstable injuries may improve diagnostic accuracy.

To identify the timing and method of diagnosis, diagnostic reliability of screening lateral radiographs, effect of delayed diagnosis, complications of treatment, and neurologic outcome of this life-threatening condition.

Diagnosis of craniocervical dissociation (CCD) was frequently delayed, increasing the risk of neurologic decline. Early diagnosis and stabilization protected against worsening spinal cord injury.

This study highlights the importance of disciplined evaluation of the lateral cervical spine radiograph of poly-traumatized patients. Head-injured patients with cranio-facial trauma and asymmetric high cervical spinal cord injuries should heighten clinicians’ suspicion of CCD.

CCD was identified or suspected on two of seventeen (12%) initial lateral cervical spine radiographs, and on screening CT scan in only two additional patients (12%), despite an abnormal dens-basion relationship in 16/17 (94%) patients. Of the thirteen patients with (two-day average) delay in diagnosis, 5/13 (38%) had profound neurologic deterioration. One patient worsened temporarily after fixation. There were no pseudarthroses at fifteen-month average follow-up. Mean ASIA motor score of fifty improved to seventy-nine, and the number of patients with useful motor function (ASIA D or E) increased from seven (41%) preoperatively to thirteen (76%) postoperatively.

Four patients with severe craniocervical instability had < 3 mm displacement. We therefore adopted a classification based on provocative traction testing of minimally displaced injuries.(Table).

Retrospective review of seventeen consecutive CCD survivors identified between 1994–2002 through institutional databases. Radiographic and clinical results were evaluated, emphasizing timing of diagnosis, effect of delayed diagnosis, clinical or radiographic warning signs, and response to treatment.

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Pilon injuries without fibula fractures may be associated with increased tibial plafond fracture severity. To evaluate this, we used the rank order technique, with traumatologists blinded to the fibular injury, who ranked the radiographic severity of forty pilon injuries with and without fibula fractures.

Pilon injuries with fibular fractures were ranked as more severe than those without. C-type injuries were ranked as more severe than B-type. Fibular fracture was more frequently associated with C-type injury than B-type. The presence of an intact fibula is not predictive of a more severe injury to the tibial pilon.

To determine if the absence of a fibular fracture is predictive of tibial pilon fracture severity.

Fibular status is not predictive of a more severe injury to the tibial pilon, and is more commonly associated with the less severe B-type injuries.

Absence of an ipsilateral fibular fracture in patients with tibial pilon injuries may predict a more severe tibial plafond injury pattern. Presumably, the energy is completely absorbed by the tibia resulting in more severe epimetaphyseal injury. The reverse relationship, however, was identified. This fact may aid in prognosis and treatment strategies.

Twenty consecutive pilon injuries without associated fibular fractures were matched 1:1 to an age/gender-matched cohort of pilon injuries with fibular fractures. Initial radiographs were digitized, the fibular image concealed, and then independently ranked (One, least severe; forty, most severe) by three orthopaedic traumatologists according to tibial plafond fracture severity. Injuries were classified using AO/OTA guidelines.

Inter-observer agreement was moderate (κ =0.6). Mean rank for pilon injuries with fibula fractures was 24.4 versus 16.7 for those without (t = 0.02). C-type injuries demonstrated a mean of 10.3 for those with fibular fractures versus 8.7 for those without (t = 0.5). Mean rank for B-type injuries was 11.1 versus 24.5 for C-type injuries (t = 0.001).

Overall, tibial pilon injuries with fibular fractures are more severe than those without. C-type injuries with or without fibular fractures are equally severe. C-type injuries were ranked significantly more severe than B-type. Fibular fracture was more frequently associated with C-type injury than B-type.

Two collagen type IX gene polymorphisms that introduce a tryptophan residue into the protein’s triple-helical domain have been linked to an increased risk of lumbar disc disease. To determine whether a particular subset of symptomatic lumbar disease is specifically associated with these polymorphisms, we performed a prospective case-control study of 107 patients who underwent surgery of the lumbar spine. Patients were assigned to one of five clinical categories (fracture, disc degeneration, disc herniation, spinal stenosis without spondylolisthesis and spinal stenosis with spondylolisthesis) based on history, imaging results, and findings during surgery. Of the 11 tryptophan-positive patients, eight had spinal stenosis with spondylolisthesis and three had disc herniation. The presence of the tryptophan allele was significantly associated with African-American or Asian designation for race (odds ratio 4.61, 95% CI 0.63 to 25.35) and with the diagnosis of spinal stenosis with spondylolisthesis (odds ratio 6.81, 95% CI 1.47 to 41.95).

Our findings indicate that tryptophan polymorphisms predispose carriers to the development of symptomatic spinal stenosis associated with spondylolisthesis which requires surgery.

Introduction Sacral fracture-dislocations with cauda equina deficits are high-energy injuries, the treatment of which is controversial. The effect of early decompression and stabilization is unclear. Neurologic recovery has not been objectively evaluated in past series, putting into question reported recovery rates. Sacral anatomic constraints make standard principles of fracture reduction, neural decompression and stable fixation difficult to apply. Lumbo-pelvic fixation allows indirect fracture stabilization by transferring loads directly from the acetabulum to the lumbar spine, thus avoiding the difficulties inherent in achieving sacral fixation. The purpose of this study was to determine the results of sacral decompression and lumbo-pelvic fixation for sacral fracture-dislocations, with neurologic deficits, using an objective method to evaluate neurologic recovery.

Methods We have carried out a complete retrospective review of all medical records, original radiographs, and prospectively collected data of 18 consecutive patients with sacral fracture-dislocations and cauda equina deficits identified between 1997 and 2002 through institutional spine and trauma databases. Fractures were classified according to Denis (1), Roy-Camille (2) and Strange-Vognsen (3). All were treated with open reduction, sacral decompression and lumbopelvic fixation. Radiographic and clinical results of treatment were evaluated. Neurologic outcome was measured by Gibbons’ criteria (4).

Results Sacral fractures healed in all 18 patients without loss of reduction. Average sacral kyphosis improved from 41° to 24°. Fifteen patients (83%) had normalization or improvement of bowel and bladder deficits, although only 10 patients (56%) had improved Gibbons scores. Average Gibbons type improved from four to 2.8 at 19 month average follow-up. Rod breakage (33%) and infection (17%) were the most common complications. Recovery of bowel and bladder function was more likely in patients with intact lumbosacral roots (86% vs. 36%,p=.066) and incomplete deficits (100% vs. 47%, p=.241) although the small cohort size precluded statistical significance.

Conclusions Lumbo-pelvic fixation safely and effectively provided the stability necessary for mobilization and weight-bearing without loss of reduction in polytraumatized, neurologically impaired patients undergoing extensive sacral decompression. Although neurologic improvement was noted in 83% of patients only 56% of patients had measurable recovery according to objective criteria. However, the functional improvement noted in most patients and complete recovery of bowel and bladder function in all but one patient with intact sacral roots are encouraging.

Introduciton Diagnosis of cranio-cervical dissociaton is frequently delayed, and neurological consequences may be severe. Our purpose was to identify problems with the diagnosis and treatment of craniocervical dissociation, while reporting the results of early craniocervical fusion with posterior segmental fixation.

Methods We present a retrospective review of 17 survivors of cranio-cervical dissociation identified through institutional spine and trauma registries. Medical records, radiographs, and prospectively collected data were used to identify the timing and method of diagnosis, and the effect of delayed diagnosis. Radiographic and clinical results of treatment were evaluated. Emphasis was placed on identifying missed or delayed diagnoses, decline in neurologic function, potential clinical or radiographic warning signs, and response to treatment.

Results Despite an abnormal Basion-Dens relationship in all but one patient, cranio-cervical dissociation was identified or suspected on the initial lateral cervical spine radiograph in only two patients (12%), and was diagnosed in only four patients (24%) following initial trauma evaluation (lateral radiograph and CT of cervical spine). The two day average delay in diagnosis was associated with profound neurologic deterioration in five patients. One patient had post-operative neurologic worsening. No patients developed craniocervical pseudarthrosis or hardware failure after a 15-month average follow-up period. The mean ASIA motor score of 50 improved to seven, and the number of patients with useful motor function (ASIA D or E) increased from seven patients (41%) pre-operatively to 13 (76%) post-operatively. The typical patient profile was of a polytraumatized patient with associated head injuriy, cranio-facial trauma, and asymmetric motor deficits extending above the C5 level.

Conclusions Better clinician awareness and disciplined review of screening C-spine radiographs are important for prompt diagnosis and stabilization of craniocervical instability. Of 17 patients with CCD necessitating internal fixation (stage two and three), 13 had a delay in diagnosis either at our institution or the transferring hospital, with severe neurological consequences in five patients. Significant recovery of neurologic function was a consistent post-operative finding, confirming the importance of prompt diagnosis and operative stabilization of these devastating injuries.